Selective Mutism: Cognitive- Behavioral Intervention

The subject of intervention for children with Selective Mutism has been addressed by several researchers and clinicians. While there have been more than 90 studies of intervention with children who have SM, very few of the existent studies used randomized controlled trial methodology. Many of the articles are case presentations or had only a limited number of research subjects. This article will review the work of researchers who recently completed randomized controlled trials on Cognitive-Behavioral Intervention and published their results.

A cognitive-behavioral approach is a psychosocial intervention that also involves some aspects of behavioral treatment. Variations of cognitive behavioral therapy may include other strategies such as:

Play therapy

Role-playing

Audio/video self-modeling

Oerbeck, Stein, Pripp, and Kristensen (2015) published a one-year follow-up study of children with SM who had received cognitive behavioral therapy (CBT). In their pilot study, 24 children (aged 3 to 9 years) received CBT for six months and were then re-evaluated after one year. These children had been diagnosed with SM, and since their most difficult speaking situations occurred at school, these researchers looked at the use of CBT in the school and preschool settings.

In this CBT protocol, the therapist uses “defocused communication” and behavioral interventions. Defocused communication requires that the therapist do the following:

Sit beside, rather than opposite, the child

Create joint attention using an activity that the child enjoys, rather than focusing on the child

“Think aloud” rather than asking the child direct questions

For example, if the child enjoys working a puzzle, the therapist and child sit at a table, side by side, and take turns selecting pieces to put into the puzzle. The therapist talks about what they are doing, such as “I have a puzzle piece that shows the feet of the man.” When the child picks a piece, the therapist might say, “Now you have the man’s head in that puzzle piece.”

The principle for the behavioral intervention is to reward the child immediately if he or she talks to adults with a normal, or near normal, voice. Several details are important here. First, the therapist must give the child enough time to respond and not talk for the child. If the child doesn’t speak the therapist should continue the dialogue even if the child does not respond verbally. Second, if the child does respond verbally the therapist should receive the response in a natural way (e.g., if the child says “I have the biggest piece,” the therapist might then say, “Yes, you have the biggest piece”) rather than praising the child for speaking. The principals of defocused communication and behavioral intervention are then used in settings that are gradually more challenging to the child with SM.

Among the advantages of the CBT interventions described here is that they are easy for parents and teachers to use over the long term. They also help perpetuate the child’s efforts because they are naturally rewarding.

It is expected that young children, upon beginning school, will be able to use expressive language to communicate with their teacher and their peers. Negative educational and social outcomes can occur when children lack this essential skill.

Children who persistently withhold speech or who fail to speak in social situations in which it is expected (usually at school), despite speaking normally in other situations (usually at home), have been identified as being “selectively mute.” Selective Mutism is diagnosed when the refusal/failure to speak interferes with educational or social achievement.

This course will discuss the criteria, causes, comorbidities, and treatments for this rare disorder, detailing behavioral, psychosocial, and cognitive behavioral interventions. Essential points will be illustrated by the inclusion of a real-life case study.

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